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General NPI Number Information
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NPI Number | 1689125080
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Entity Type | Organization
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Legal Business Name | NJ VISION CARE LLC
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Dates
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Enumeration Date | 10/20/2016
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Last Update Date | 10/20/2016
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Provider Practice Location Address
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Address Line | 1151 LIBERTY AVE #B
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City | HILLSIDE
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State | NJ
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Zip | 07205-2143
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Country | US
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Telephone | 908-351-0420
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Fax |
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Provider Business Mailing Address
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Address Line | 5 LAWRENCE ST APT PH32
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City | BLOOMFIELD
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State | NJ
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Zip | 07003-4631
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | GUSTIE M CHRISTOPHER
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Credential | OD
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Telephone | 305-879-9881
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 27OA00662002
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License Number State | NJ
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